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    <h4 class="text-center title">— 东营市医疗保险转院备案表 —</h4>
    <table class="table table-bordered text-center table-condensed">
        <thead>
        <tr>
            <th width="10%"></th>
            <th width="15%"></th>
            <th width="10%"></th>
            <th width="15%"></th>
            <th width="10%"></th>
            <th width="15%"></th>
            <th width="10%"></th>
            <th width="15%"></th>
        </tr>
        </thead>
        <tbody>
        <tr>
            <td>姓名</td>
            <td id="patientName"></td>
            <td>性别</td>
            <td id="patientSex"></td>
            <td>年龄</td>
            <td id="patientAge"></td>
            <td>人员类别(职工/居民)</td>
            <td id="patientType"></td>
        </tr>
        <tr>
            <td>身份证号码</td>
            <td id="patientSfzh"></td>
            <td>拟就诊医院(限一家)</td>
            <td id="rollOutHosp"></td>
            <td>科别</td>
            <td id="rollOutHospRank"></td>
            <td>联系电话</td>
            <td id="patientPhone"></td>
        </tr>
        <tr>
            <td>病情摘要</td>
            <td colspan="7" id="illnessSummary"></td>
        </tr>
        <tr>
            <td>诊断</td>
            <td colspan="7" id="diagnosis"></td>
        </tr>
        <tr>
            <td>转院原因</td>
            <td colspan="7" id="rollOutReason"></td>
        </tr>
        <tr>
            <td class="longText" colspan="8" style="height:120px;vertical-align: top">
                <p>
                    <span>转诊次数：</span>
                    <span class="mr50">自</span>
                    <span class="mr50">年</span>
                    <span class="mr50">月</span>
                    <span>日</span>
                    <span class="mr50">至</span>
                    <span class="mr50">年</span>
                    <span class="mr50">月</span>
                    <span>日</span>
                    <span class="mr50">，共需转诊</span>
                    <span>次</span>
                </p>
            </td>
        </tr>
        <tr>
            <td class="longText" colspan="8">
                <p>
                    <span class="mr100">参保人签字：</span>
                    <span class="mr100">医师签字：</span>
                    <span class="mr100">科主任签字：</span>
                </p>
                <p class="fr">
                    <span class="mr50">年</span>
                    <span class="mr50">月</span>
                    <span class="mr50">日</span>
                </p>
            </td>
        </tr>
        <tr>
            <td class="longText" colspan="8">
                <p style="height:40px;"><span>医院医疗保险管理机构意见：</span></p>
                <p style="display: flex;justify-content: flex-end"><span class="mr100">( 盖章 )</span></p>
                <p class="fr">
                    <span class="mr100">经办人签字：</span>
                    <span class="mr50">年</span>
                    <span class="mr50">月</span>
                    <span class="mr50">日</span>
                </p>
            </td>
        </tr>
        <tr>
            <td class="longText" colspan="8">
                <p style="height:40px;"><span>社会保险经办机构意见：</span></p>
                <p style="display: flex;justify-content: flex-end"><span class="mr100">( 盖章 )</span></p>
                <p class="fr">
                    <span class="mr100">经办人签字：</span>
                    <span class="mr50">年</span>
                    <span class="mr50">月</span>
                    <span class="mr50">日</span>
                </p>
            </td>
        </tr>
        </tbody>
    </table>
    <div class="content">
        <p style="font-weight: bold">说明：</p>
        <p>1.参保人转院前须填写本表，医师应据实填写各项内容，医院盖章后参保人持本表及社保卡或身份证到社保经办机构办理转外就医备案手续，每次备案有效期为15天，超出有效期须重新备案。</p>
        <p>2.参保人一个年度内(自办理首次转院备案起计算)因相同原因，需多次转往同一家医院住院的，由医师填写第四项内容，参保人可在每次转院前持本表复印件到社保经办机构办理转外就医备案手续，在对定点管理医疗机构考核时，转诊数量累计计算。</p>
        <p>3.本表仅限选择一家拟就诊医院，参保人需一次转往多家拟就诊医院的，应分别开具。</p>
        <p>4.本表一式三份，定点管理医疗机构，参保人和社保经办机构各执一份。</p>
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